Purposes of the Medical Record
                           Communication                                                  Legal documentation
                           Communication                                                  Legal documentation
                           Reimbursement                                                                Education
                           Reimbursement                                                                Education
                                    Research                                              Auditing/monitoring
                                    Research                                              Auditing/monitoring
                                                        Copyright © 2017, Elsevier Inc. All Rights Reserved.                                                   2
              The Shift to Electronic Documentation
           HITECH established provisions to promote the 
                 meaningful use of health information technology 
                 (HIT) to improve the quality and value of health 
                 care
           Experts believe that implementing EHRs across 
                 the health care delivery system will decrease 
                 costs and improve the quality of patient care
           Difference between EHR and EMR
           EHR attributes, components, and advantages
                                                        Copyright © 2017, Elsevier Inc. All Rights Reserved.                                                   3
                       Interprofessional Communication 
                                   Within the Medical Record
           The quality of patient care depends on your 
                 ability to communicate with other members of 
                 the health care team.
           When a plan is not communicated to all 
                 members of the health care team, care becomes 
                 fragmented, tasks are repeated, and delays or 
                 omissions in care often occur.
                                                        Copyright © 2017, Elsevier Inc. All Rights Reserved.                                                   4
                                Confidentiality
         Nurses are legally and ethically obligated to keep all 
            
                       patient information confidential.
          Nurses are responsible for protecting records from 
                             all unauthorized readers.
                HIPAA requires that disclosure or requests 
             regarding health information be limited to the 
                                minimum necessary.
                                Copyright © 2017, Elsevier Inc. All Rights Reserved.       5
                                                             Quick Quiz!
          1. Information regarding a patient’s health status may not 
                 be released to non–health care team members because: 
          A. legal and ethical obligations require health care 
                 providers to keep information strictly confidential. 
          B. regulations require health care institutions to document 
                 evidence of physical and emotional well-being.
          C. reimbursement issues related to patient care and 
                 procedures may be of concern.
          D. fragmentation of nursing and medical care procedures 
                 may be identified.
                                                        Copyright © 2017, Elsevier Inc. All Rights Reserved.                                                   6